Answers to six questions about anxiety in children and teens

Between school and social demands, lots of children feel stress, but at what point does anxiety cross the line and become a mental health concern? We sat down with Keneisha Sinclair-McBride, PhD, a clinical psychologist in the Department of Psychiatry at Boston Children’s Hospital, to better understand what separates serious forms of anxiety from normal worrying, whether seeing a therapist is warranted, and how to handle anxiety at home.

1. My child is a ‘worrier.’ What degree of anxiety is normal and what should cause me concern?

Occasional worries, like concerns about the start of the school year or fitting in with peers, are normal and part of social development. Temperament and personality differences will make some children bigger worriers than others. If your child can face and overcome worries through positive methods, like talking with you and through enjoyable activities, then the anxiety is likely manageable and normal.

Worries become concerning when they significantly affect your child’s functioning. Some children will be clingy, shy, or refuse to participate in activities because of their fears. Significant crying, trouble sleeping, or behavior problems related to worries can be warning signs of an anxiety problem.

2. Should my child see a therapist, and what kind? 

If worrying is causing your child to struggle at home, at school, or socially, it may be time to seek outside help. In addition, if your child has panic attacks (extreme physical reactions to anxiety that can appear out of the blue), phobias, or compulsive behaviors, discuss the possibility of therapy with your pediatrician.

Many different types of behavioral health providers can help your child manage anxiety and learn ways to cope. Psychologists have doctorate degrees and training in assessment, diagnosis, and therapy for mental health problems. Social workers, licensed professional counselors, and marriage and family therapists have master’s degrees and training in therapy or counseling. Any therapist you consider should have experience working with children or adolescents and use cognitive behavioral therapy (CBT) to treat anxiety. CBT helps children adjust their thoughts and behaviors and has proven efficacy.

3. How should I mention the idea of therapy to my child?

Normalizing your child’s experience is important. Older kids and adolescents may take comfort in knowing that about 1 in 5 people in the U.S. have an anxiety disorder. Participating in therapy is also very common. Reassure your child that just as a teacher or sports coach may have taught him a new skill, a therapist can help him learn how to reduce anxiety and feel better about himself. Stress that you want to support him, and that he hasn’t done something wrong. Hearing that there is very real hope of feeling better often does more for a child’s self-esteem than avoiding the issue.

4. I know my child is worrying, but she won’t tell me why. How can I get her to open up?

Some children are embarrassed or afraid parents will find their worries silly. They need to hear that worries are normal and that you think their concerns are important. You can mention a worry of your own, such as running late or not doing a good job at work, and ask if your child ever has similar thoughts. Or, when she brings up friends or school, ask what sort of things her friends worry about. If you notice a situation where she looked worried, you can bring it up later in a non-judgmental tone, letting her know you noticed her concern. Explain that you want to help her feel happy and safe and that you’re here for her when she’s ready to talk.

5. Should we consider medication?

A trial of CBT with a skilled therapist should almost always be completed before considering medication. CBT is often just what children and teens need to successfully manage anxiety and learn coping skills. If your child’s symptoms are extremely debilitating or get worse, discuss the options with your pediatrician or behavioral health provider. You may be referred to an adolescent psychiatrist, although some pediatricians prescribe medication for anxiety themselves.

6. What can I do to help my child with anxiety?

Here are a few approaches to try:

• Cultivate positive coping skills. Enjoyable physical activities like sports, exercise, or simply playing outside can offer distraction, release nervous energy, and improve mood. More subdued activities like coloring or journaling can have a calming effect. Stress balls and fidget toys can offer sensory soothing. You can practice relaxation strategies like deep breathing, progressive muscle relaxation and guided imagery with your child. A variety of phone and tablet applications can help teach these skills.
• Help your child face fears through gentle exposure. Anticipatory worries are often worse than the thing itself. Help your child address worries in a safe, organized way. If your child is fearing a birthday party, agree to stay for the first 15 minutes. If your child fears dogs, introduce them to a calm and gentle dog. Successfully facing fears increases confidence and encourages children to face fears in the future.
• Limit reassurance-seeking. Instead of constantly talking about worries, set aside 10 minutes day (not close to bedtime) as a “worrying time.” Worries are be discussed, written down or even put in a “worry box.” If your child brings up worries at other times, remind them to use their coping skills, adding that you are happy to discuss their worries at the appropriate time.
• Encourage good sleep “hygiene.” Poor sleep habits can affect mood and make it harder to control worries. Make sure your child is getting the age-appropriate amount of sleep. Limit screen time as bedtime draws near and focus on quiet, calming activities. You can learn more about healthy sleep habits here and here.

Learn more about Boston Children’s Outpatient Psychiatry Services.